What is the next step for a 62-year-old female factory worker with persistent back pain, despite 6 weeks of physical therapy, who works 2 jobs on concrete?

Next Step for Persistent Back Pain After Failed Physical Therapy

After 6 weeks of failed physical therapy, this patient should receive medication management (NSAIDs or acetaminophen as first-line) combined with continued activity modification and self-care education, with reassessment in 4 weeks before considering imaging. 1

Why Imaging Is NOT Indicated Yet

• The American College of Physicians explicitly states that imaging should not be obtained until symptoms persist beyond 4-6 weeks of conservative treatment, and this patient has only completed physical therapy without a trial of appropriate medications. 1, 2

• Routine imaging in nonspecific low back pain does not improve patient outcomes and leads to unnecessary interventions and increased healthcare costs. 1, 2

• The radiation exposure from a 2-view lumbar spine radiograph delivers gonadal radiation equivalent to daily chest x-rays for over one year—particularly concerning in women. 2

• Most acute low back pain improves substantially within the first month, with 90% of patients experiencing benign courses. 3, 4

Red Flags That Would Change This Approach

None of the following appear to be present based on the clinical scenario:

• Progressive motor or sensory deficits 1, 4
• Cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction, bilateral leg weakness) 2, 4
• Severe or rapidly progressive neurological deterioration 5
• History of cancer, recent spinal procedure, or suspected infection 1, 4
• Significant trauma relative to age 4

Appropriate Next Steps: Medication Management

First-line medication options include: 1

• NSAIDs: More effective than acetaminophen for pain relief (approximately 10 points better on 100-point visual analogue scale), but carry gastrointestinal and renovascular risks. 1

• Acetaminophen: Slightly weaker analgesic but safer profile and lower cost, making it reasonable first-line therapy despite being less effective. 1

• Consider skeletal muscle relaxants for short-term use if muscle spasm is prominent. 4

Additional Conservative Measures to Implement

The patient should receive: 1

• Advice to remain active: More effective than bed rest; she should continue working with appropriate activity modifications rather than complete rest. 1

• Self-care education: Evidence-based materials like "The Back Book" are inexpensive and nearly as effective as costly interventions like supervised exercise or acupuncture. 1

• Heat application: Heating pads or heated blankets provide short-term relief for acute low back pain. 1

• Medium-firm mattress: Firm mattresses are less likely to improve chronic low back pain compared to medium-firm options. 1

Occupational Considerations

For this factory worker on concrete: 1

• Consider her age (62), general health, and physical demands of her job tasks when advising about activity limitations. 1

• Evidence is insufficient to guide specific recommendations about modified work, but brief individualized educational interventions can reduce sick leave in workers with subacute low back pain. 1

• If this is a worker's compensation claim, refer to state-specific regulations as rules vary substantially. 1

When to Reassess and Consider Imaging

Reassessment should occur in 4 weeks: 1, 2

• If symptoms persist after 4-6 weeks of comprehensive conservative management (medications + activity modification + self-care), then plain radiography may be reasonable as initial imaging. 1, 2

• Earlier reassessment is appropriate if she develops severe pain, functional deficits, or signs of radiculopathy or spinal stenosis. 1

• If radiculopathy develops and persists beyond 6 weeks of optimal medical management, MRI without contrast becomes the preferred imaging modality. 2

Common Pitfalls to Avoid

• Do not order imaging before completing 4-6 weeks of comprehensive conservative management unless red flags are present. 2

• Do not assume physical therapy alone constitutes adequate conservative treatment—medication management is a separate, evidence-based component that must be tried. 1

• Do not recommend complete bed rest—remaining active is more effective and prevents deconditioning. 1

• Do not overlook psychosocial factors—job dissatisfaction, depression, and passive coping strategies predict poorer outcomes and may require additional interventions. 1